I LOVE EPIDURALS


©CathiStack2019


I am a fan of epidurals, period.  I know I may not be in the majority of midwives, but I love them.
Epidural anesthesia is regional anesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide analgesia, or pain relief, rather than anesthesia which leads to total lack of feeling. Epidurals block the nerve impulses from the lower spinal segments. This results in decreased sensation in the lower half of the body, which affects women differently.  Some have a complete loss of sensation, some are able to move well and still have excellent pain relief and some may only feel pressure. Unfortunately, some epidurals don’t end up working well. Sometimes the block is only noted on one side and this may or may not be fixed.  Often, in the case of a baby that is too big for moms pelvis (only we don’t know it yet), the mom who initially had a good epidural will become uncomfortable again and request many “top-off’s”. A top-off is a bolus dose of medication given through the epidural catheter that should once again get mom comfortable.  An occasional top-off is not unusual as labor progresses but when she continues to become uncomfortable with minimal labor progress, the writing's on the wall for a potential cesarean section unless we can get that baby to change positions. Labor nurses have a gift when it comes to changing baby positions. The recently infamous peanut ball (literally looks like a giant Mr. Peanut) has helped to rotate many a baby to a better delivery position (occiput posterior to occiput anterior).
Intravenous (IV) fluids will be started before active labor begins and prior to the procedure of placing the epidural. You can expect to receive a liter of IV fluid prior to an epidural. An anesthesiologist (specialist in administering anesthesia), an obstetrician, or nurse-anesthetist will administer your epidural. You will be asked to arch forward and remain still while lying on your left side or sitting up. This position is vital for preventing problems and increasing the epidural effectiveness.
The procedure takes 10-20 minutes and most of it is opening up the sterile kit and getting the medications ready.  An antiseptic solution will be used to wipe your mid back and small area on your back will be injected with a local anesthetic to numb it.   This feels like a bee sting or as I tell patients, a pinch and a burn. A needle is then inserted into the numbed area surrounding the spinal cord in the lower back.  This is typically not painful but feels more like someone is pressing a thumb to your back with quite a bit of pressure. After that, a small tube or catheter is threaded through the needle into the epidural space. The needle is then carefully removed, leaving the catheter in place to provide medication either through periodic injections or by continuous dosing.  The catheter is taped to the back to prevent it from slipping out. Don’t worry they will tape it well. Once you are all taped up, you should be much more comfortable within about 10 minutes.
What I love about epidurals
I love that the patient gets to sleep through the worst of their labor.
I love that we typically push for less than an hour for a first baby instead of three.  (Nurses will agree)
I love that moms are present in the moment, not under the influence of narcotics.  I love that I do not have to pull them from another planet to be present during their birth as they are exhausted from the pain and duration.
I love that there is typically very little to repair when the birth is controlled and I can protect the perineum (skin between the vagina and rectum) from tearing or at least, minimize it.  I recently was asked by an intern who had watched a few of my “intact” deliveries how I protected the perineum. The trick is when the head looks to be half way out, a good epidural will let you sit there for a minute or maybe the next contraction.  This is nearly impossible, although I have seen it done, in a woman without an epidural. It is this moment of stretching that saves you from tearing. Epidurals help prevent a vaginal blowout. When pushing is a bit hectic and there is little control due to the intensity, sometimes the baby will exit a bit more rapid than we’d like causing tears in a few different directions.  Not to worry though, the vagina is ultra forgiving and heals very well in a short amount of time.

If a Cesarean Section is needed, everything is already in place and we can use it (with a bit more medication).
What I don’t love about epidurals
A very common drop in blood pressure that may result in a drop in the baby’s heart rate.  This rarely results in an emergency, but it can sure scare the parents. I describe it like this:  When you go from such an intense state to such a relaxed state in a short period of time, the common drop in blood pressure results in a more relaxed blood flow through the placenta with may then precipitate a temporary drop in the heart beat or short term deceleration's.  This typically resolves after a few positions changes and a bolus of IV fluids. For the parents to be, this could be a bit scary when 4 people come running into the room to check on their co-worker who’s patient has a drop in heart rate. Parents, be relieved that everyone is paying close attention.
Mom’s will not be able to get out of bed or move well without assistance.  This is a bit of a bummer to both of us. If the mom-to-be is a bit fluffy, this makes changing positions (which we want them to do frequently) difficult which takes a toll on the nurse's body.  Back and shoulder issues on not uncommon in the labor and delivery staff.  
The use of a catheter is common in order for the bladder not to become over distended and prevent the baby’s head from coming down.  If it is not your first baby and things are moving fast we may be able to avoid this or use a straight catheter which is inserted and removed one the bladder is emptied (a minute or two).  
Less than 1% of women who receive an epidural will experience a spinal headache.  A spinal headache is caused by the leakage of spinal fluid due to a puncture in the cord.  The headache is severe when the patient is sitting up but not while lying down. In some cases a blood patch may be done.  This all sounds terrible (and the headache is) but all will be well very soon without long-term issues.  
The shakes.  Some women experience the shakes or shiver shortly after the initiation of the epidural.  This typically doesn’t last long but is very annoying to the patient and has nothing to do with being cold.
Once an epidural is turned off (typically after delivery), it may take up to two hours to get sensation back into your lower extremities.  So you won’t be jumping into the shower right away.  
A small percentage of women will experience mild back discomfort for 2-6 weeks after delivery.  This is not enough to even take a Motrin for, but enough to notice.  
Some women experience a low-grade fever and the common denominator seems to be the epidural.  Not much to worry about but we may see mom and baby’s heart rate go up a bit as it is a normal response to an elevation on body temperature.  

NO EPIDURAL FOR YOU IF…
There are some conditions or complications where an epidural may post too much of a risk to the patient.  This usually has something to do with issues in blood clotting. If you are currently on blood thinners and have not been removed prior to labor, you may not be a candidate for an epidural.  Same goes if you have low platelets. There is no magic number but it will depend on the comfort level of your anesthesiologist. Most anesthesiologist will do an epidural if the platelets are above 100,000
An active infection including herpes that is anywhere near the epidural site will make it a big fat “no” for an epidural.  Remember, it is our job to keep you safe. Spreading an infection to your spinal column will have a potentially horrible outcome.  We know you will survive the pain of labor.  
If your labor is moving a mile a minute…. You will likely miss your epidural.  This does not usually go over well, but I assure you, it will be over so quick and all will be well.  
Obesity makes the epidural very difficult to administer.  I have actually had doctors tell their patient that they are too fat to get an epidural, but usually it’s worth a try.  What many people don’t understand is the anesthesiologist needs to be able to feel the spaces in your back (between the vertebrae) in order to place the catheter.  Excess fat makes this very difficult and it typically takes a bit longer to do. If you are obese, we are not judging you but please understand that this makes the task much more difficult.

When I am judged by the fact that I do like epidurals, as a midwife, I have to remind myself what the word and true meaning of midwife means, -- “with woman”, and I am.  No matter what her choice, I will only give her my opinion if she asks.  

Catherine (Cathi) Stack is owner, facilitator and Doctor of Naturopathy at Journey II Health, LLC established in 2007 and currently located in Niagara Falls.  Along with her naturopathic practice that specializes in colon health and bio-identical hormone replacement, Stack is a practicing staff midwife at Millard Fillmore Suburban Hospital.  She currently writes articles for local, national and international publications. Cathi’s first book, “Free Yourself from a CONSTIPATED Life”, is a multi award winning book available on Amazon as well as her newest, “PUSH, Labor & Delivery from the Inside Out.” Visit www.cathistack.com for more info.



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